2D 2 eae eels E el Ae 6 * 
. 


COLUMBIA LIBRARIES OFFSITE ‘it 
HEALTH Ai STANDARD | re 


| 
HX64076580 
RA644.T7 F71 A seven years’ campa 
>... 


RECAP © 


im 


7 


Columbia Giversity 
inthe City of Hew Pork 


College of Physicians and Surgeons 


Library 


’ if ie by the Internet Archive © i 


in 2010 with funding from i nm 
- Open Knowledge Commons 


iene 
Tie WO, 
LR Li) 
Sais oT 
‘ 


ay Ng | 
DADE Ber Se 


A Seuen Years Campaign 


Review of Manoeuvers and Statement of Results 
of the Tuberculosis movement in 
New York State outside of 
New York City 


By Homer Folks 


Secretary of the State Charities Aid Association 


Published by 


Tuberculosis Committee 
State Charities Aid Association 


RESULTS OF THE SEVEN YEARS’ CAMPAIGN AGAINST TUBERCULOSIS 
IN NEW YORK STATE OUTSIDE OF NEW YORK CITY. 


Address delivered at opening sessions, State Conference of Tuberculosis 
Workers, Syracuse, November 11th and 12th, 1914. 


MR. HOMER FOLKS, 
Secretary, State Charities Aid Association. 


It happens to be just seven years ago that the Committee on Tuberculosis of the 
State Charities Aid Association was formed, and a representative of the staff went 
to Utica to make a tuberculosis survey. Now a good many things have happened 
since that time. In summing them up I am not in the slightest degree concerned, 
nor is the State Charities Aid Association, with who is responsible for what has 
been brought to pass. We are far too busy to undertake to apportion the credit 
for what has happened even if any one wanted it done. I am not speaking of what 
the State Charities Aid Association any more than anybody else has accomplished. 
They are the accomplishments of the entire people of the State of New York. 
If any class, more than another, were to be commended, it is public officials, the state 
officers, the legislature, members of boards of supervisors and health officers, one 
and all. If ever there has been co-operative effort, it has been in this tuberculosis 
movement. My only object, however, is to try to show how far, working all to- 
gether, we have got. 


When we set out we did not undertake to lay out any detailed program of what 
to do, because we did not know what would develop and did not know what chiefly 
needed to be done. We hoped, however, to learn by doing and to begin by finding 
out the facts in a particular locality and proceed from that to shape our course. 


LEGISLATION. 


We had not a single item of legislation in mind at the outset. It developed, 


however, within the first year that it was the judgment of those concerned, and © 


particularly of the local authorities and health officers of the different cities vis- 
ited, that certain new laws were necessary. I wish first very hastily to recall what 
has been done in the matter of legislation since the fall of 1907. 


Those of you who have to do with the law making will recognize at once that 
there is nothing more uncertain, few things more difficult than legislation. Looking 
back over these seven years, to the best of our recoliection and our records, there 
is not a single bill which the tuberculosis workers of the State have framed to pre- 
sent at Albany which has not become a law. I think there has not been a year, 
certainly not more than one year, in which we have not had occasion to present one 
or more and often five or six bills. It is also equally true that during that period 
of seven years not a single bill which the Committee has seriously opposed has 
reached the statute books. 


Now I attribute that to two things, Firstly, to the widespread interest in the | 


subject which has been aroused and to the recognition of that fact on the part of 
the Legislature. There are few things which secure a more immediate response and 
recognition at Albany than anything pertaining to tuberculosis. Secondly, to the 
fact that the Committee has tried to be extremely careful and thorough in the prepa- 
ration of its measures, taking always every step into account and especially recog- 
nizing the experience of other States. 


Let me give a brief summary of the legislative work of the Committee. The 
following bills drafted by the tuberculosis committee have become law. 


1908—Providing for the Registration of Cases and Their Sanitary Supervision in 
Their Homes. 


1909—Authorizing Counties to Establish Tuberculosis Hospitals (Law has been a 
Model for 7 States.) : 


1913—The Committee Took a Leading Part in Getting Most Important and Far- 
reaching Changes Made in the Public Health Law and in the State Health 
Department. 


1914—Referendum to Voters of Initial Appropriation for Establishment of Country 
Hospitals. 


Authorizing County Hospital Managers to Erect Additional Buildings Needed 
Instead of Board of Supervisors. 


Restoring to County Hospital Managers Authority to Fix Salaries of Employees. 


Authorizing County Hospitals to Employ Visiting Nurses and to Take Such 
Steps as They Deem Necessary to Prevent the Disease. 


Authorizing the Laity to Report Apparent Cases of Tuberculosis to the Health 
Officer for Investigation. 


Bills Drafted that Became Law—9; Failed—None. 
Bills Supported that Became Law—/7; Failed—2. 
Bills Opposed that Became Law—None; Failed—l6. 


The first two, enacted in 1908 and 1909 respectively, have been amended occas- 
ionally to meet the growing needs of the movement, but I think it is greatly to the 
credit of the tuberculosis workers of the state that during the entire period that 
those laws have been on the statute books there has never been, to my knowledge, 
a single suggestion in any quarter by any individual however obscure or however 
celebrated that either should be repealed. On the contrary every year they have been 
made more enforceable and more effective. 


The latest amendments to the tuberculosis law included a provision which would 
have been utterly beyond the wildest dreams of any one in 1907, namely the authori- 
zation of the commitment by magistrates of dangerous cases of tuberculosis. This 


bill, we had been repeatedly told, could never be passed in the State of New York, 
but it did pass substantially without opposition. 


HOSPITAL PROVISION. 


The next subject that I wish to review in general is that of hospital provision. 
At the outset in 1907 the matter of hospital care did not assume great proportions 
as a feature of prevention. I think it is fair to say that none of us were in the 
least degree aware of the importance which that matter was to assume. We were 
thinking of sanatoria and of the care of curable cases, but only to a very slight de- 
gree of the segregation of moderately advanced and advanced cases as a matter of 
public protection. 


It was the International Tuberculosis Congress in 1908 in Washington which 
brought together from many countries and from many different groups of workers, 
isolated facts which when put together unmistakably spelled segregation as the 
great feature in the campaign. That was quite as unforseen and quite as unexpected 
by those who went to the Congress as any one result of that gathering. The things 
that were there set forth and the facts that were made known diminished our faith 
in dispensaries, nurses and supervision as preventative measures of largest signifi- 
cance. That is, their limitations were disclosed as they had not been disclosed 
before, and the Congress correspondingly emphasized the necessity of hospital 
care of advanced cases. Furthermore, it emphasized the necessity for local hospital 
care for advanced cases. All of us would gladly have gone on with easier things, 
that did not involve large expenditures of money for establishment and maintenance, 
but we felt that we could not in justice to the cause and with self-respect and 
intellectual consistency do otherwise than undertake to secure hospital provision on 
a comprehensive scale throughout the State. No matter how difficult and no matter 
what the obstacles to be overcome, that was the big thing and of all other things 
it was the most important to work for. Thus it came about that the county tuber- 
culosis hospital law was enacted in the winter of 1909. Not that that was to be the 
only type of tuberculosis hospital, but that it was a type which could be established 


in any given county. 


‘Now as time has passed it has become in a way increasingly difficult to secure 
the establishment of these hospitals. It was much easier in 1910 and 1911 than it 
was in 1913 and 1914, because of the fact that since 1909 a great many other large 
expenditures have been forced upon the counties. The tax rates have been in- 
creased, and they are more and more loath to add to their expenditure. Those 
expenses included the cost of maintenance of armories, the enormous cost of the 
new election and primary laws, the local share of the cost of good roads; their 
maintenance and the interest on the sums expended and several other large sums. 


The result in general terms in spite of these drawbacks, however, has been 
most encouraging, and results, in a way, is the crucible test of whether we have been 
going ahead or not. In 1907 there were three hospitals in the State of New York 


outside of New York City, with a capacity of 178 beds. To-day there are 24 hospitals 
in actual operation and one soon to be opened. These 25 hospitals have a total 
bed capacity of 1,673. In other words the bed provision has multiplied by nine in 
that period of seven years. And besides those actually in operation there are 13 
additional local hospitals definitely authorized and assured. For five of those sites 
have been secured, and for eight others the authorities are now engaged in the 
selection of sites. Those 13 hospitals are planned to have a bed capacity of 1,296. 
There is in more or less immediate prospect, therefore, hospital provision for 
nearly 3,000 patients. 


One thing we have learned, is that it is a long way from the desire for a 
hospital to the opening of it; that the number of obstacles that can arise in securing 
a site and in getting plans and in the appointment of a Board of Managers are 
simply legion; and that they are often serious and exceedingly baffling and embar- 
rassing. But nevertheless it has taught us that patience and perseverance can 
dissolve those difficulties in almost every case. Notwithstanding all those difficulties 
however, I have no hesitation in submitting to the scrutiny of any authority what- 
soever, the hospitals that are now operating. In the main I believe they will stand 
careful analysis from every point of view. Of course they were not primarily in- 
tended for cure. The main point was not the treatment of curable patients at the 
outset or even now, but the protection of the community by means of segregating 
those in a dangerous condition. That object at least is secured irrespective of any- 


thing else. 


DISPENSARIES. 


When the work began the dispensary was put very much in the foreground. 
Our primary purpose, substantially, in going to any locality was to urge the establish- 
ment of a tuberculosis dispensary. I am inclined to think that as the years have 
passed the importance of that, in and of itself and as distinguished from certain 
other things that have been added to it, has rather diminished. It hasn’t proven to 
be as essential a factor in the situation as we had thought it might. Nevertheless 
in 1907 where there were two dispensaries in the State outside of New York City, 
there are to-day 27, a good many of which are carried on by municipalities and 


some by tuberculosis committees. 


THE VISITING NURSE. 


Much was said at the outset about visiting nurses. Insofar as they were thought 
of as an important part of the situation, it was as appendages to the tuberculosis 
dispensaries for the purpose of visiting and supervising the patients registered at 
the dispensaries. Now, when seven years have gone by, the visiting nurse has © 
steadily increased in importance as a factor in the situation, entirely aside from 
or in addition to her relatioi to the dispensary and to the dispensary patients. We 
have come to realize—when I say that I speak broadly in the sense of all of us— 
that we might have known at the outset if we had thought that far about it, that 


the great majority of tuberculosis patients are not under any oversight at all. They 
are unrecognized cases. A great many of them do not know that there is anything 
the matter with them. A still greater number do recognize that they are not in 
first-class condition but haven’t the remotest idea of what is the matter and are not 
seeking medical attention. Of the relatively small number who do seek medical 
attention only a comparatively small proportion are recognized as being cases of 
tuberculosis. 

The most valuable function which the trained nurse has come to perform in the 
general state-wide movement is that of finding out where the tuberculosis patients 
are while they are still alive. Heretofore in an overwhelming majority of instances 


they only came into notice when the death certificate was filed. The trained nurse 
has proved to be the most effective agency, I was about to say the only agency, for 
finding them while they are still alive, while they can be helped and while their 
families can still be protected from the danger of infection. The visiting nurse has 
proved to be a most important factor—(a) in finding out where cases are; (b) in 
bringing them to the notice of physicians; (c) in bringing to the knowledge of the 
community and of its public authorities an actual picture of the conditions that 
exist; (d) in putting before them a definite knowledge in place of an indefinite 
statement; (e) in putting it in terms of human beings having a legal habitation and 
a name; (f) in bringing home to the community a concrete knowledge of the situa- 
tion as compared with the general knowledge of the situation. 


In 1907 there were 2 visiting tuberculosis nurses outside of New York City, now 
there are 66. Except for hospital provision, I think that is distinctly the most im- 
portant result that has been obtained. It is gratifying and suggestive that of those 
sixty-six nurses, thirty are employed by cities as part of their municipal machinery, 
and two are employed by counties. A majority of the nurses, therefore, are part of 
the organized community action for dealing with tuberculosis in a broad and com- } 
prehensive manner. I predict that as time goes on the visiting nurse will more and | 
more be a part of the protective side of municipal government. 


RELIEF OF FAMILIES. 


It was also early seen that an essential supplement to hospital provision was || 
special charitable relief for families. I very well remember along about 1907, hearing |, 
one of the leading clergymen of Rochester express a good deal of gratification at the 
splendid development of the relief system of the city. He said that they eumevca 
most in Rochester from poverty of ideals and not poverty of the material resources i 
of life. I differed from him a bit, and he asked me how they could improve things ' 
further. I suggested that if he consulted the death records he would get a very | 


good text from which to preach. 


He was disposed to think everything was done substantially that had to be done, 
and I mentioned tuberculosis, as a possible field in which much remained to be done. 


I thought people did not go to hospitals or did not stay there because they were too 
poor and the families were not looked after. ‘“Why,!” he said, “that might be so. 
Come to think of it right here in this street, which is perhaps the wealthiest street 
in Rochester, there is a man going in and out of a certain house every day tending 
to fires who just came out of our municipal tuberculosis hospital. Now that I 
think of it he came out because he got worried about his family; he was afraid that 
his children and his wife were not being looked after suitably.” 


That is a very fair picture of the situation as it existed. The entire relief 
business needed to be overhauled so far as it concerned the tuberculosis families. It 
had to be not simply adequate for the maintenance of existence, but adequate to 
satisfy the tuberculosis patient that his family was well cared for while he remained 
away. Special relief for families in which there was tuberculosis was, therefore, one 
of the problems. There were two cities in the beginning that made special effort for 
the relief of tuberculosis families. Now there are 41. 


REPORTING AND REGISTER OF CASES 


Reporting of cases of tuberculosis by physicians and their registration and su- 
pervision was one of the important objects to be attained. The importance, of the 
reporting the cases by physicians, has somewhat diminished. Even if they reported 
all that came to their knowledge it would only be a small part of the number. 
Even this has not yet been done. But the reports by physicians beginning in 1907 
were 2,500, and they have increased reasonably steadily from year to year. In 1909 
the reported cases exceeded the number of deaths for the first time. In 1913 there 
were 8,449 reported cases, one and one-half times the number of deaths. I am not 
disposed to emphasize the value of these figures, because I believe that up to 
this time there is no means of eliminating duplicates. The same patient may be 
reported by his private physician, by the dispensary if he goes to one, by the hospital 
to which he may be admitted and again by the- same locality to which he may return 
—and he may count for four. But the figure does show a very substantial increase 


in the number of cases reported. 


SUPERVISION OF CASES IN THEIR HOMES. 


The plan contemplated a supervision. Of course reporting is just a means to 
an end. If nothing is done about the case reported, it isn’t worth while to have it 
reported. The law outlined a procedure of sanitary supervision of each household in 
which there was a case, by the physician reporting it if he desired to do it, or by 
the health officer if the physician preferred to turn it over to him. 


On the whole that has been the least enforced of all the provisions of the Law. 
I have not at all lost faith in its effectiveness and its possibility. It was a concession 
to the private physician that he was given the first opportunity to perform this duty, 
and I think that a survey would show that there is not very much happening in a good 
many localities. In some localities it is being done, but there has never been the 


follow up work that was necessary to make that provision of the law effective. 


In the nature of the things, tuberculosis cases could only be followed up effec- 
tively by the health officers. He was not likely to do it effectively unless he were 
followed up in turn by his superior, the State Health Department. The State Health 
Department until lately had neither the disposition nor the facilities wherewith to 
follow up the health officer in observance of this law. We may look for a great 


improvement in the near future. 


POPULAR EDUCATION. 


Another aspect of the movement was what we called popular education, efforts 
to bring home to the community the facts that were known to the medical profession 
in regard to tuberculosis. Now it isn’t very easy to make any definite statement 
to measure that result. You can only occasionally see straws which show the way 
the wind blows, and you can keep more or less of a record of what has been done. 
You are all familiar with the fact that tuberculosis as a cause has been “put on the 
map.’ Leaflets have been distributed, not only by the hundreds of thousands but 
by millions. The newspapers have decided that the subject is news. You can 
hardly pick up a paper anywhere in the State without finding. something in it about 
tuberculosis. I should suppose that as good a measure of the result of that as we 
can get is the recent referendum on the establishment of tuberculosis hospitals in 
four countries of the State. The County hospital law was amended last winter, 
authorizing the board of supervisors to submit the question of establishing a hospital 
to the vote of the electorate, the proposition submitted providing for a direct appro- 
priation. I should suppose that there could hardly have been a more unfortunate 
year than this for testing the effectiveness of our educational campaign. The stock 
exchange is closed, business is more or less at a standstill, and the election of state 
officers was pending. Everybody was feeling in a general way that it was time to 


slow down. 


In viewing the results of the campaign it must be recalled that an educational 
campaign is most difficult in rural counties. Those four counties are perhaps as 
rural a four counties as could be found. There are no large cities. In three there 
are no cities at all and the fourth one has a city of 8,000 inhabitants. 


The following table shows the results in the four counties and makes an in- 
teresting and significant comparison of the vote on the hospital with the total vote 


for Governor: 


Population 
(Federal Vote Majority 
Name of Census Total Vote Total Vote Vote for against for 
County 1910) on Hospital on Governor Hospital Hospital Hospital 
Saftolk:.. a 96,138 16,751 18,651 9,525 7,226 2,299 
Chenango ... 35,575 7,868 7,958 4,919 2,949 1,970 
WCE WAS & sinus y ats 24,849 4,960 4,992 2,803 257 646 


ASSAM Seat. 83,930 13,439 16,299 6,798 6,641 157 


It will be seen that almost as many persons voted for the hospital as voted for 
Governor. In as much as a minority of the voters many times decide important 
questions submitted to them, this result is significant of the effect of our edu- 
cational efforts. People know that tuberculosis is preventable and are willing to 
tax themselves to prevent it. 


THE NEW HEALTH LAW. 


There are some bi-products of any such movement as this running over a 
period of years which could not be foreseen at the beginning. One of the bi-products 
of the tuberculosis movement as a whole, is undoubtedly of greater importance than 
any direct results that we aimed at. You never know the strength and adaptability 
of a tool until you try to use it; until you measure it up against a good-sized job. 
The English people did not realize the weakness of their army until they had to 
fight the Boers. The Russians did not know their weakness until they fought the 
Japanese. The state did not know the effectiveness of its entire health machinery, 
including the health law, the local health officers, the local health board and the 
State Department until it was measured up against a good big job. The glaring 
inconsistencies in the law, the enormous gap between the local health officer and 
the State Department became apparent only when the whole apparatus was measured 
up against as big a job as the prevention of tuberculosis 


Now in no spirit whatever of criticism, and merely for the purpose of utilizing the 
fact that the term of office of the health commissioner was coming to a close for an 
improvement instead of a retrograde in the situation, those primarily interested in 
the tuberculosis work sought and secured the appointment of a special health com- 
mission a year ago last winter. That Commission would have been unable to operate 
effectively except for the aid given it by our tuberculosis committee. We cast our bread 
upon the political waters of the State, confident that in due season it would return. 
We placed our staff, or a portion of it, and our time and our means, such as they 
were, at the service of that Commission. We can properly say, speaking broadly, 
that whatever of change has occurred in the State Health Department, in the Public 
Health Law, in the last two years, is a bi-product of the tuberculosis movement. 


How great that change is and what it forecasts for the future of the State, 
not only as to tuberculosis, but as to all sorts of things, I am not sure we, any of 
us, fully realize. I suppose the health officers realize it more than the people gen- 
erally. It seems to me impossible that it was only a year ago that the health officers 
of the State were in conference in the city of Utica; that the chief authorities of 
the Department were openly ridiculing the work of the Public Health Commission, 
throwing all kinds of doubt on the new public health law and recommending the 
abolition of the Public Health Council. Now we have a Department with a com- 
missioner of the highest authority. He has brought from Washington the best vital 
statistician in the country, and you can accept statistics that come from that office 
exactly at their face value. The diagnosis from the state’s laboratory can now be relied 
on and human life can safely be staked on their results; communicable diseases are 


handled by the safest men in the State of New York, the educational work of the 
Department is in the hands of a man who knows public health education as few 
men in the country know it. The sanitary supervisors for the State have been 
appointed as the result of a competitive examination. It seems impossible that only 
one year has passed since last November, and that all these things could have been 
accomplished in that short time. 


If nothing else had happened except that, I for one should be more than satis- 
fied with results of all the effort devoted to the tuberculosis campaign for the last 
seven years. 


Much more than that, however, has resulted in the way of bi-products. One 
of the extremely important things is the public health efforts of the organized 
farmers of the State. For a number of years there has been no more effective 
supporter of advanced health legislation and of hospitals and dispensaries and nurses 
than the State Grange. They rank their health work as equal in importance with 
their advocacy of the parcels post and good roads. That is a force that counts 
enormously when you get to Albany. The labor unions and the women’s clubs are 
also active in their support of health legislation and represent intelligent public opinion 
when they speak to the legislature. 


Other groups have not responded in a large organized way that you might think 
would have responded. I haven’t heard of any bar associations doing anything 
about it. The clergymen help in meetings and in talking about it; but not in organ- 
ized pushing. But the women’s clubs, the farmers and the labor unions can be 
counted on every time, and without their aid we could not have gotten anything 


like as far as we have. 


I am not going to stop to talk about the results as shown in the mortality fig- 
ures, because I do not believe that it does show yet in any large way. While the 
death rate from tuberculosis has diminished—while it averaged 137 per 100,000 popu- 
lation in the seven years prior to 1907, and since then it has been 131, 130, 125, 123, 
126, 114, 115—I would not claim at all that those figures measured the direct result 
of what has been done. I do not believe that the statistics are sufficiently reliable 
or that diagnosis is sufficiently uniform to give the figures much meaning. They do 
show, however, that there has been an effect, and that we may look for an increasing 
effect in the future. That it has been due directly to what has been done in the move- 
ment in which we have all been so engrossed in the last seven years I should express 
some doubt, particularly by reason of the fact that the death rate was decreasing 
to a certain extent, before the campaign began. 


One or two other indirect results are worth noting. The effect upon the 
communities of the State of addressing themselves to this subject has been of in- 
calculable value. President Cleveland once called attention to the value to the 
individual of doing something for somebody. That is quite as applicable to a 


community. I do not think that any one thing has done the governments of the 
counties, cities, towns and villages of the State so much good in the last seven years 
as to be brought face to face with this loss of human life, and to be asked what they 
were going to do about it. The local government and the local citizenship of the 
State of New York have learned a lesson in these seven years that is an inestimable 
asset in all our community life for the future. It has learned to deal with tuber- 
culosis. It has come to see a public duty in saving human life, in protecting in- 
dividuals from infection. It has learned a lesson that will be applied in countless 
other ways, and never again will the person interested in his fellow human beings 
meet such a dead wall of uninformed indifference as was met in a great many cases 
at the beginning of these seven years. I would be disposed to put that result very 
high in the scale of the ultimate value of things accomplished by the tuberculosis 
movement. 


In closing I wish to express a word of gratitude to the people who have really 
stood behind this thing and have preferred to be substantially unknown. Nothing 
happens without some backing. It takes money to carry on any sort of an organized 
movement. Promotion is difficult and expensive. Into the work of unifying and 
coordinating and promoting this tuberculosis work there has been put, beginning in 
1907, with $10,000, sums which at the largest have been $31,000 and recently not 
less than $26,000. Roughly speaking about $180,000 has been put into what might 
be called the central organization in promoting the work. All that has been made 
possible by the far-sightedness of the trustees of the Russell Sage Foundation, who 
from the beginning have financed the work of the tuberculosis committee of the 
State Charities Aid Association. 


vt 


et 


COLUMBIA UNIVERSITY LIBRARIES 


This book is due on the date indicated below, or at the 
expiration of a definite period after the date of borrowing, as | 
provided by the rules of the Library or by special arrange- | 
ment with the Librarian in charge. / 


DATE BORROWED DATE DUE DATE BORROWED DATE DUE 


IH 
a 


¢28(1141)M100 


"Olks ( ~ieel 


A seven yearer 


N ; 
sid 30 1944 C. U. Rinne... 


oi A 


